Choice Plan - Express Scripts

DrugNameDrugTierRequirements/Limitsclindamycin phosphate1 GC MOaddvantageclindamycin phosphate in d5w inj 1 GC300mg/50ml; 5%, 600mg/50ml;5%clindamycin phosphate in d5w inj 1 GC MO900mg/50ml; 5%COARTEM 2 MOcolistimethate sodium 1 GC MOCUBICIN 2 PA MODAPSONE 2 MODARAPRIM 2 MOethambutol hcl 1 GC MOgentamicin sulfate inj 1 GC MOgentamicin sulfate/0.9% sodium 1 GCchloride inj 0.9mg/ml; 0.9%,1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%,1mg/ml; 0.9%hydroxychloroquine sulfate 1 GC MOimipenem/cilastatin 1 GC MOisoniazid syrp 1 GC MOisoniazid tabs 1 GC MOisotonic gentamicin inj 0.8mg/ml; 1 GC0.9%, 1.2mg/ml; 0.9%KETEK 2 QL(20 per30 days)MOMALARONE 2 MOmefloquine hcl 1 GC MOMEPRON 4 MOmeropenem inj 500mg 1 GC MOmetronidazole 1 GC MOmetronidazole in nacl 0.79% 1 GC MOMYCOBUTIN 2 MONEBUPENT 2 PA MOneomycin sulfate tabs 1 GC MOparomomycin sulfate 1 GC MOPASER 2 MOPRIMAQUINE PHOSPHATE 2 MOpyrazinamide 1 GC MOQUALAQUIN 2 MOquinine sulfate 1 GC MODrugNameDrugTierRequirements/Limitsrifampin 1 GC MOSEROMYCIN 2 MOSIRTURO 4 LA MOSTREPTOMYCIN SULFATE 2 MOSTROMECTOL 2 MOtinidazole 1 GC QL(60per 90 days)MOTOBI 4 PA MOtobramycin sulfate inj 10mg/ml, 1 GC MO80mg/2mltobramycin sulfate/sodium 1 GCchloride inj 0.9%; 1.2mg/mltobramycin sulfate/sodium 1 GC MOchloride inj 0.9%; 0.8mg/mlTRECATOR 2 MOTYGACIL 2 MOXIFAXAN TABS 200MG 2 QL(9 per 30days) MOXIFAXAN TABS 550MG 2 QL(180 per90 days)MOZYVOX INJ 2 MOZYVOX SUSR 2 QL(1800per 30 days)MOZYVOX TABS 2 QL(56 per30 days)MOPENICILLINSamoxicillin 1 GC MOamoxicillin/clavulanate potassium 1 GC MOchewamoxicillin/clavulanate potassium 1 GC MOeramoxicillin/clavulanate potassium 1 GC MOsusr 250mg/5ml; 62.5mg/5ml,400mg/5ml; 57mg/5ml,600mg/5ml; 42.9mg/5mlamoxicillin/clavulanate potassium 1 GC MOtabs 250mg; 125mgamoxicillin/potassium clavulanate 1 GC MOsusr 200mg/5ml; 28.5mg/5mlamoxicillin/potassium clavulanatetabs1 GC MO5